Crazy?

"…she's got on these diapers and she climbs on me and sits on my belly and laughs. I mean, I know she's not really there, but I see her so clear. I call her Charity," Erlinda shyly explains.

Erlinda watches me closely then looks away, embarrassed. "Am I crazy?" she wants to know. What can I say? I hear the pleasure in her voice as she tells me about this toddler and I search for the right words to support this 33-year-old woman who has just completed her first year of sobriety and her first full year of complying with the medication her psychiatrist prescribed.

When I met her 18 months ago, Erlinda was using crack and had not been on medication to treat her symptoms of manic depression. She had just been kicked out of one shelter and was looking for a place to stay. She took a huge risk revealing this vision to me and now was awaiting a response that could be the difference between continued trust and using crack. Is there something wrong with her talking to an image of a happy toddler?

We are living in stressful times. We are all seeking safety and security in a world of continuing uncertainty. Daily I am expected to provide solace to individuals whose emotional pain makes finding security difficult. As a psychiatric social worker I assist my clients in learning how to tolerate a world without stability.

Treatment has two distinct and coordinated aspects. Medication is effective for reducing symptoms. Voices can be diminished and depression can be lifted. The other half of treatment emphasizes learning how to manage life's daily stresses.

Erlinda and I meet regularly to talk about tolerating the chaos of having four children in her home. We discuss teenage behavior and methods for communicating with her 13- and 16-year-old daughters. Her treatment includes learning to be a parent and watching for signs that her mood may be getting out of control.

After surviving the devastation of sexual abuse, she ran away from home at 14 and had her first child when she was 15. Now, 18 months after first meeting, she has completed a substance abuse program and has moved into independent housing. Her goal now is to focus on education. She wants to keep her kids in school and to get her GED.

Who am I to say that she is crazy for using Charity to stay sober? Mental health is not about a rigid set of rules each person must follow to stay out of a hospital. Helping her manage her symptoms, live independently and cause no harm to herself or others is the simple goal of treatment. Erlinda's toddler is helping her attain that goal.

As her sobriety and symptom management continue, we focus more on the events leading her to leave home at 14. Examining her history comes when she is stable enough to manage the pain of such recalled memories. Telling me about Charity lets me know she is ready to talk about those events.

Health care providers today are required to be aware of the entire person—to understand that a stomach ache is not just the result of eating the wrong thing, but is part of a patient's inner physical, psychological and external environments. Effectively supporting the client, I and the doctor work to insure compliance with her treatment plan.

Each treatment plan includes, along with medication, counseling and participation in appropriate groups or classes. Erlinda has completed a ten week parenting class and regularly attends dual diagnosis (substance abuse and psychiatric diagnosis) groups. I am the bridge between the patient and her psychiatrist—allowing Erlinda to describe her "weird" images of Charity without being described as "crazy."

Another client's fear of being labeled "crazy" is so great he is unwilling to take medication to control the voices and his fears. Mickey called me saying "you got to get me a place to stay. They'll kill my sister and her kids if I don't get out." His fears may be real. He is also sure I will contact his parole officer. This fear has been controlled in the past with medication. Mickey is unable to consider the possibility that his fear can be managed. The only time he has been effectively treated is when he was incarcerated. When he is outside, he won't take medication and the symptoms return.

My work requires that I am able to hear the requests of people whose voices are commanding him to "kill yourself" and still maintain a sense of security. Watching my patients grow and make changes has taught me to appreciate that one person's security is not another's. At the same time I must respect the patient's choice to remain unmedicated.

I am pleased that Erlinda successfully moved out of the sober living house into an apartment with all four of her children. And I am frustrated that I can't persuade Mickey to take the antipsychotic meds that will manage his fears.

And yes, I reassured Erlinda that talking to this baby was a healthy way of soothing herself.